Tactical Medicine News Blog

A 55 year old male was brought to the Emergency Department (ED) by paramedics complaining of weakness and chest discomfort. His past medical history was notable for coronary artery disease with bypass grafting, diabetes mellitus, and end stage renal disease. He reported being non-compliant with his last 2 scheduled hemodialysis sessions. Paramedics noted pallor and recorded a blood pressure of 80/palpated and a heart rate of 44. Upon arrival to the ED, a 12 lead ECG was obtained.

Five Days at Memorial by Sheri Fink (@sherifink) invites us to examine what we expect of ourselves in the medical community during times of disaster: what is demanded by our Emergency Medicine training in triage, disaster management, and end of life care, and what ethics form the foundation of our practice when systems around us fail. Dr. Fink’s book offers an opportunity for us, as health care practitioners, to openly discuss with the communities we serve the ethics that crash into conflict in settings of unfathomable duress and insufficient resources.

Case Writer:  Brent Thoma, MD MACase Editors: Teresa Chan, MD and Nikita Joshi, MD This procedural sedation simulation case can be used to teach, evaluate or reinforce the skills needed to safely perform procedural sedation. It presents a new format for the ALiEM Sim Case Series: Teresa Chan (@TChanMD) has worked magic to amalgamate all of the materials into a cohesive, organized, easy to follow format that also happens to be pretty. The freely downloadable PDF below includes:

The case from this week is from one of the PGY-1 residents at University of Texas Health Science Center at San Antonio (UTHSCSA).  Several of the details of the case have been changed to keep patient information confidential. 53 year old female with a past medical history of hypertension, hyperlipidemia, coronary artery disease, and 3 anterior myocardial infarctions s/p 4-vessel CABG (LIMA-LAD, RIMA-RCA, SVG-D1-OM1 sequentially) 9 months ago who presents with intermittent 10/10 chest pain that radiates to his left arm for the past 6 months. The chest pain is associated with nausea and shortness of breath but denies diaphoresis or syncope. Patient reports that the pain is the same as his index chest pain and is both exertional and non-exertional and will often wake him up from sleep. The pain can last 5-10 minutes and is always relieved by rest. The patient reports good medication compliance (on metoprolol, atorvastatin, enalapril, amlodipine, aspirin). He presented with similar symptoms 3 months ago but left against medical advice before a work-up could be performed. Now he presents with increasing frequency of chest pain. BP 152/105  HR 86 RR 16 O2 sat 99% on RA   Temp 98.0 ECG from triage is shown…

While the rate of diabetes climbs, the number of patients who are using insulin pumps grows apace. Pumps appeal to physicians because they mimic normal insulin physiology with a consistent basal rate and appropriate bolus doses for meals. This leads to tighter glucose control and smaller variations. For patients, the pumps can be liberating, requiring far fewer injections than a typical multi-dose regimen. Regardless of why your patient has an insulin pump, it helps to know about how they work… for when they don’t.